Acta Anaesthesiol Scand 2000; 44: 630–632 Copyright C Acta Anaesthesiol Scand 2000 Printed in Denmark. All rights reserved ACTA ANAESTHESIOLOGICA SCANDINAVICA ISSN 0001-5172 Case Report Reciprocating tachycardia during central venous cannulation in a patient with Wolff-Parkinson-White syndrome J. C. DIZ, J. RODRIGUEZ, E. BLANCO and J. ALVAREZ Servicio de Anestesiologia y Reanimacio ´n, Hospital General de Galicia-Clı ´nico Universitario, Santiago, and Departamento de Biologı ´a Funcional y Ciencias de la Salud, Universidad de Vigo, Spain Wolff-Parkinson-White syndrome is important for the anesthesi- ologist because the sudden development of tachyarrhythmias may result in deleterious hemodynamic changes. We describe an episode of reciprocating tachycardia triggered by the inser- tion of the guide wire during central venous cannulation in a patient with this syndrome. W OLFF-PARKINSON-WHITE (WPW) syndrome is the most common of the pre-excitation syndromes, and its incidence has been estimated as 1.5 per thou- sand (1). This syndrome is especially important for the anesthesiologist because the sudden development of tachyarrhythmias may result in deleterious hemo- dynamic changes (2). The goal during management of anesthesia of these patients is to prevent tachy- arrhythmias (3), especially avoiding any circumstance that might enhance conduction of the cardiac impulse through the accessory pathways (4). An example is the overinsertion of the guide wire during central ve- nous cannulation, which can produce a mechanical ir- ritation ofthe cardiac chambers that induces ectopic activity (5). We describe an episode of reciprocating tachycardia triggered by the insertion of the guide wire during central venous cannulation in a patient with WPW syndrome. Case report A 74-yr-old woman with WPW syndrome was admit- ted for elective right hemicolectomy for cecum cancer and splenectomy for idiopathic thrombocytopenic purpura. She had been treated with oral flecainide (100 mg q 12 h) for two years, with the diagnosis of 630 Received 26 August, accepted for publication 20 November 1998 Key words: Central venous catheterization, complications: re- ciprocating tachycardia; heart, arrhythmias, Wolff-Parkinson- White syndrome. c Acta Anaesthesiologica Scandinavica 44 (2000) type A WPW syndrome (Fig. 1). Recent medical his- tory was negative for palpitations and there was no clinical evidence of arrhythmias recently. She had a history of mild hypertension and had no previous surgery. The patient had severe thrombocytopenia, and since the platelet response to corticosteroids was inadequate, with a platelet count of 24 000 per micro- liter, the patient received intravenous immunoglob- ulin three days before surgery, and the platelet count increased to 97 000 per microliter. The patient received midazolam 1 mg intravenously and was brought to the operating room. In addition to the standard ECG and pulse oximetry monitoring, we monitored the ECG in a defibrillator. An intra- venous catheter and a left radial artery cannula were inserted, recording a blood pressure of 155/85 mmHg, with a regular sinus rhythm of 72 beats/min. Anesthesia was induced with fentanyl, 0.15 mg, fol- lowed by etomidate, 10 mg, and atracurium, 30 mg. Tracheal intubation was accomplished smoothly, and administration of 1% sevoflurane with 50% nitrous oxide in oxygen was started. There were no arrhyth- mias or severe changes in blood pressure or heart rate or rhythm during this procedure. We decided to insert a catheter sheath introducer system (Baxter Intro-Flex, Edwards Critical Care Divi- sion, Irvine, CA) in the right internal jugular vein to